HospitalInspections.org

Based on interviews and document review, the hospital failed to ensure all Allied Health practitioners were granted specific privileges to provide care in the hospital.

Findings:

On 10/19/2016, a list of Allied Health practitioners was provided. Staff Z, Staff AA, and Staff GG were listed as Advanced Practice Registered Nurses (APRNs).

Although the credentialing files for the three APRNs documented that they had been granted temporary privileges, the practitioners had no defined list of privileges that they were granted.

Staff AA had requested specific privileges; however, there was no documentation the request was approved by the Governing Body.

The Co-Director of Nursing stated the lack of designated privileges was an oversight.

Based on document review and interview the hospital failed to ensure medical and nursing personnel, assigned duties for emergency care, were appropriately trained.

Findings:
Document review of staff training files and personnel files showed that three of four medical providers and nine of ten nurses either had expired ACLS, or no ACLS, training shown in their documentation. Nurse consultant/Acting DON verified these findings.

Based on observation and staff interview it was determined the facility failed to ensure their interior ceiling finish coating of asbestos was fully encapsulated.

Findings:

On 10/18/2016 at 12:53 p.m., a housekeeping office and clean storage room next to patient room 116 was observed to have a 3X7 area of wall with exposed non-encapsulated asbestos open to this area.

While on tour of the facility the surveyor observed fiber release episode areas throughout the facility in which had not been repaired and/or encapsulated.

On review of facility records revealed the composition of asbestos ceiling material within the facility to be 80% amosite and 10% chrysotile.

On 10/20/2016 at 10:45 a.m., on tour of the facility's drug room a half inch hole was observed near the ceiling of the room with a blue computer cable going through it. There was asbestos material covering the wall where the hole was drilled and loose asbestos fibers were exposed around the hole.

At 10:47 a.m., a corner of the ceiling in the drug room was observed to have water damage and the asbestos material covering this ceiling area was cracked, exposed and separated from the ceiling hanging down.

At 10:47 a.m., on another wall in the drug room a span of silver conduit was observed penetrating a wall that was covered in asbestos material and had loose asbestos fibers exposed around the hole that was drill to accommodate the conduit.

On 10/21/2016 at 10:55 a.m., on tour of the facility areas of damaged ceiling encapsulation with exposed asbestos fibers were observed in the following patient rooms:

Room 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111.

The director of plant operations acknowledged the exposed asbestos areas, and damaged encapsulated asbestos areas.

Based on observation the facility failed to inspect, and maintain HVAC systems supply and mechanical exhaust vent fans. (See Life Safety Code K-0150)

Findings:

On 10/18/2016 at 11:30 a.m., Mechanical exhaust fans, including those in toilet rooms, were not observed to not be operating or functioning. Exhaust fan grills were observed to be covered in a furry brown material.

At 11:31 a.m., room 101 was identified as the facility isolation room by facility staff. On tour of the room it was observed to not be negatively ventilated. There was no HVAC system in the room. The room had an air conditioner unit installed in the window of the room. No devices/gauges were present to indicate if room 101 was negative or positive.

Based on record review and interview the hospital failed to:
a. appropriately report drug administration errors, adverse drug reactions, or dosing issues to pharmacist or hospital quality assessment and performance improvement (QI) program, and

b. ensure assigned pharmacy personnel were appropriately trained.


Findings:
1. Documents supplied to hospital through granted program with South Western Oklahoma State University (SWOSU) College of Pharmacy show:
2 medication errors and 2 transcription errors for June 2016
1 medication errors, 1 transcription error, and 5 dosing issues for July 2016
3 dosing issues for August 2016
5 medication errors, 10 transcription errors, and 14 dosing issues for September 2016

Review of Pharmaceutical and Therapeutics (P & T) meeting notes did not show any medication, transcription, or dosing errors being discussed.
Review of quality assessment and performance improvement program meeting minutes (March, April, June, July, August, and September 2016) did not show that pharmacy had reported any medication errors, transcription errors, or dosing issues.

Interview with CEO and (Acting) CNO it was stated that pharmacist did not participate in either QI or P & T meetings.

Interview with Pharmacy Technician on October 20, 2016 at 9:28 AM. Pharmacy technician stated that she received the monthly notifications from South Western Oklahoma State University (SWOSU) College of Pharmacy, looked them over, and filed them in a binder. The information was not passed to anyone else.

2. Document review of staff training files and personnel files showed that pharmacy technician had no documented pharmacy training in their files. Nurse consultant/Acting DON verified this finding.

Based on observations, interviews, and document review, the infection control officer(s) failed to implement hospital infection control policies and adhere to infection control standards of practice.

Findings:

On 10/18/2016, during an interview, the Chief Executive Officer stated the duties of the infection control preventionist were performed by the co-Director of Nursing (DON)/ consultant (Staff KK) and Staff E. Staff KK was a former employee who had fulfilled the role of infection control preventionist in the past, and now was a hospital consultant. Staff KK was assigned to train Staff E to perform the duties of the preventionist.

Surveyors requested the Infection Control meeting minutes for the past 6 months, and only Sept 21/2016 minutes were provided. Staff KK stated Staff E had failed to maintain minutes of the quarterly infection control meetings from the earlier months of 2016. (Infection Control was a standing agenda item for the Quality Improvement Committee.)

On 10/18/2016, the surveyors requested the hospital's 2016 Infection Control Risk Assessment, and none was provided. Staff KK stated the Infection Control Risk Assessment had not been performed.

On 10/18/2016, the surveyors requested the list of disinfectants that were approved by Governing Body for use. Although a list was provided, no evidence was given showing approval for use by the Governing Body.

On 10/18/2016 at 11:31 a.m., room 101 was identified as the facility isolation room by facility staff. On tour of the room it was observed to not be negatively ventilated. There was no HVAC system in the room. The room had an air conditioner unit installed in the window of the room. No devices/gauges were present to indicate if room 101 was negative or positive.

On 10/20/2016, during an interview, the Chief Executive Officer and Staff KK Preventionist stated they had not validated the infection control conditions of their contracted linen service.

The hospital policy titled, "Employee Health Immunizations" was reviewed. The policy documented all employees are required to have measles, mumps, rubella (MMR)vaccine or titer; varicella vaccine or titer; tuberculosis (TB); influenza; Hepatitis B vaccination, titer, or declination."

On 10/20/2016 & 10/21/2016, the nineteen clinical health files (including the physicians and allied health) were reviewed. The immunization findings of the review was as followings:
~TB:
12 of 19 did not have documented compliance with hospital policy. (Staff # A, C, H, N,O, R, S, AA, CC, GG, NN, Z)
~Influenza:
14 of 14 did not have documented compliance with hospital policy. (Staff # A, B, E, F, H, I, M, N, O, R, S, CC, DD,NN) (Employees hired in 2016 were not included in that the 2016 vaccination had not begun).
~Hepatitis B:
12 of 19 did not have documented compliance with hospital policy. (Staff # E, F, H, N, O, R,S, Z, AA, CC, GG, NN)
~MMR:
11 of 19
did not have documented compliance with hospital policy.(Staff #E, H, N, O, R, S, Z, AA, CC, GG, NN)
~Varicella:
11 of 19 did not have documented compliance with hospital policy. (Staff #E, H, N, O,R, S, Z, AA, CC, GG, NN

On 10/18/2016, the surveyors toured the following areas and found the following infection control issues:
Kitchen
~Fly swatters laying on table in kitchen
~Office areas with cork boards and papers at kitchen entrance (difficult to clean/disinfect)
~fan was near the food preparation area

Patient Care Areas
~Tape on handles of shower chair (difficult to clean/disinfect)
~Multiple patients room's contained wood furniture and wood closets that were unfinished and porous and difficult to clean
~Fly swatters laying on table two patient rooms (115 and 101).
~Shower room had chipped paint (difficult to clean/disinfect).
Storage
~Two misting tents, loosely covered with a plastic bag, had a dusty cleaning log book stored on it. The cleaning log refected the last cleaning was 2011.

Lab
~The room that contained clean lab supplies, also was used as the staff lounge. The room contained a small dining table, food, lockers and an open housekeeping floor sink.

Based on interviews and document review, the hospital failed to ensure that contracted services were evaluated for safety and effectiveness.

Findings:
On the morning of 10/18/2016, a list of contracted services was reviewed. No documentation was provided showing that contracted services had been evaluated by the governing body, who was responsible for oversight.

The hospital's Chief Operating Officer confirmed that contracted services were not evaluated by established quality criteria.

Based on record review and interview the hospital failed to:

a. measure, analyze, and monitor quality indicators to improve the effectiveness and safety of their services.
b. ensure the performance improvement projects were developed and measurable progress was demonstrated.
c. appropriately report drug administration errors, adverse drug reactions, or dosing issues to pharmacist or hospital quality assessment and performance improvement (QI) program.

Findings:

1. On 10/20/2016, the Quality Improvement (QI) Meeting Minutes from March 2016 through September 2016 were reviewed. Each month, multiple departmental reports were presented within the committee meeting.

The Emergency Department (ED) report was not part of this standing agenda. The QI meeting minutes did not contain any reports from Physical Therapy, which was a contracted service. The minutes reflected Physical Therapy was "unavailable at this time."

Of the QI meeting minutes reviewed, the QI Committee did not show evidence that improvement opportunities were analyzed, trended, and a comprehensive plan was developed and evaluated.

The Chief Operation Officer stated the average inpatient census was 4-5 patients per day.

On 10/20/2016, the Quality Improvement (QI) Meeting Minutes from March 2016 through September 2016 were reviewed. Each month, multiple departmental reports were presented within the committee meeting. The Emergency Department (ED) report was not part of this standing agenda. The QI meeting minutes did not contain any reports from Physical Therapy, which was a contracted service. The minutes reflected that Physical Therapy "unavailable at this time."

The following are examples of departmental events discussed in the QI meeting minutes:

Nursing
~An intravenous (IV) catheter was inserted pointed downward (proper insertion is opposite to that placement with the catheter towards the heart). The misplacement had resulted in the patient's arm swelling.
~ A patient discharged with special needle still in place in the chest's IV port.
~ Multiple meeting minute entries of nurses complaining of being "short handed".
~A patient came to emergency department (ED) with chest pain 40 minute delay in assessment
~Orders were noted by RN, but not entered into the computer. The QI meeting minutes documented, "This has happened before."

Radiology
~A computerized tomography (CT) of abdomen / pelvis films had been done with an Xray of Kidney Ureter Bladder (KUB) was ordered.
~Old scanner's computer system was incompatible with new scanner's computer system, "so we are unable to pull up archived ."
~ 05/05/2016 CT images were unable to be sent for interpretation.
~07/01/2016 CT would not go through to Telemed service for interpretation. The minutes documented the patient with possible appendicitis transferred before getting report.
~X-ray table wouldn't move and repairman was called. No discussions documented regarding the impact on care.
~The computer on CT would not open to copy the exam to disc.
~The QI minutes reflected data from multiple month for the "repeat" rates for Xrays. Four of the six months of compliance percentage calculations were incorrect. (03/01/16: 9/105=89%, 04/14/2016: 8/146=61% , 06/09/16: 14/122=75%, and 07/16: 11/117=89%).

Laboratory
~A blood lab test was not drawn for a patient.
~The server was having to be restarted everytime the computer was down.
~A blood tests for a to measure a medication's peak and trough values were not drawn, not coordinated with the medication administration as ordered.
~A cardiac enzymes was ordered every 8 hours x4- one lab was not drawn.
~The autofax was not working for a period of time. Although it was repaired, the minutes documented there were "still some instances of where it is hanging up."
~A blood lab test was grossly hemolyzed and the test could not be analyzed.
~A urine sample was labeled and logged with different name.
~A duplicate orders resulted in patient getting additional venipuncture.
~A mislabeled specimen
~The computers not communicating with analyzer which resulted in a delay in ordering, testing and resulting of samples.
~Blood lab orders were missed on 2 separate patients. The minutes documented, "Lab orders are being missed too many times."
~Two computers were not communicating.
~ A delay in the nursing staff ordering a urinalysis.
~ The nursing staff brought samples to lab with no order entered into the computer.
~A pap smear was put into wrong container.


Pharmacy
The QI minutes reflected discussions regarding the changes in the formulary, medication costs, and expirations. There was no documentation for broad strategies for reducing medication errors.

The QI minutes cited the following medication errors, but did not document discussions of the medication error results gathering by State University (SWOSU) College of Pharmacy grant project. (see Tag 286)

5/19 Percocet 10/325 given for Norco 10/325
05/12 Percocet given for Tylenol #3
6/7/16 Stadol 2mg IV given instead of 1mg

The QI Committee did not show evidence that improvement opportunities were analyzed, trended, and a comprehensive plan was developed and evaluated. Percentages were not calculated correctly, and no goals or benchmarks comparisons made. Plans for evaluation of learning needs not assessed. Analysis of error patterns relating to specific staff or staff shortages were not conducted.

2. On 10/21/2016, the Nursing consultant/ co- Director of Nursing (DON) stated the hospital's Infection Control Committee was monitoring antibiotic usage.

~The co-DON stated that the antibiotic, Vancomycin, was often used at the hospital and the medication was expensive. No information analyzing and evaluating that antibiotic was provided.

~2016 Quality Improvement, Infection Control, and Pharmacy & Therapeutic meeting minutes were reviewed. No discussions were documented regarding antibiotic use and stewardship. There was no broad analysis of the program or measures of intervention to improve the hospital's antibiotic use. There was no evidence provided the Pharmacist participated in the program.

3. Documents supplied to hospital through granted program with South Western Oklahoma State University (SWOSU) College of Pharmacy show:
2 medication errors and 2 transcription errors for June 2016
1 medication errors, 1 transcription error, and 5 dosing issues for July 2016
3 dosing issues for August 2016
5 medication errors, 10 transcription errors, and 14 dosing issues for September 2016

Review of Pharmaceutical and Therapeutics (P & T) meeting notes did not show any medication, transcription, or dosing errors being discussed.
Review of quality assessment and performance improvement program meeting minutes (March, April, June, July, August, and September 2016) did not show that pharmacy had reported any medication errors, transcription errors, or dosing issues.

Interview with CEO and (Acting) CNO it was stated that pharmacist did not participate in either QI or P & T meetings.

Interview with Pharmacy Technician on October 20, 2016 at 9:28 AM. Pharmacy technician stated that she received the monthly notifications from South Western Oklahoma State University (SWOSU) College of Pharmacy, looked them over, and filed them in a binder. The information was not passed to anyone else.